Comorbidity of eating disorders and bipolar affective disorders

Eating disorders--anorexia nervosa, bulimia nervosa and eating disorders not otherwise specified (EDNOS) occur usually in young females. The significant pathogenic differences between patients who only restrict food, and patients with binge eating and compensatory behaviours, such as vomiting and purging were described. The prevalence of bipolar affective disorders--especially bipolar II and bipolar spectrum disorders (BS) may reach 5% in the general population. About half of the depressive episodes are associated with a "mild" bipolar disorder, and such a diagnosis is suggested by impulsivity and mood-instability. Previously, majority of research on the comorbidity between eating and affective disorders focused on depressive symptomatology, however difficulties in the reliable assessment of hypomania may obfuscate the estimation of the co-occurrence of eating disorders with BS. Epidemiological studies suggest the association between BS and eating disorders with binge episodes (bulimia nervosa, anorexia- bulimic type and EDNOS with binge episodes). Co-occurrence of such disorders with depressive symptoms probably suggests the diagnosis of BS, not recurrent depression. Bulimic behaviours, impulsivity and affective disorders might be related to the impairment of the serotonergic neurotransmission, which may result from the genetic vulnerability and early life trauma. Currently, the first-line pharmacological treatment of co-occurring eating disorders with binge episodes and BS are selective serotonin reuptake inhibitors. However in some cases, the use of mood-stabilising agents as monotherapy or in combination with serotonergic drugs may be helpful.     

Pharmacologic and cognitive-behavioral treatment for bulimia nervosa: a controlled comparison.

OBJECTIVE: This study examined the relative effectiveness of desipramine, cognitive-behavioral therapy, and their combination in the treatment of bulimia nervosa, together with the effects of withdrawing medication after two different lengths of treatment. METHOD: Seventy-one patients meeting DSM-III-R criteria for bulimia nervosa, recruited from an eating disorders clinic or by advertisements, were assigned at random to one of five groups: desipramine (withdrawn at 16 or 24 weeks), combined treatment (medication withdrawn at 16 or 24 weeks), and cognitive-behavioral therapy (15 sessions). All treatments were conducted individually in an outpatient clinic. The primary outcome measures were binge eating and purging rates assessed at pretreatment, 16, 24, and 32 weeks. The results were analyzed as three groups (medication, cognitive-behavioral therapy, and combined treatment) at 16 weeks and as five groups at subsequent assessments. RESULTS: At 16 weeks, both cognitive-behavioral therapy and the combined treatment were superior to medication given for 16 weeks in reducing binge eating and purging. At 32 weeks, however, only the combined 24-week treatment was superior to medication given for 16 weeks. The combined treatment was also more effective in reducing dietary preoccupation and hunger. Continuing cognitive-behavioral therapy appeared to prevent relapse in patients withdrawn from medication at 16 weeks. CONCLUSIONS: Overall, the results favor the use of a combination of medication and cognitive-behavioral therapy in the treatment of bulimia nervosa, with medication continued for at least 24 weeks.     

Physical and sexual abuse histories in patients with eating disorders: A comparison of Japanese and American patients

Physical and sexual abuse among patients with eating disorders has been a focus of attention in Western countries, however, there is no study comparing the incidence of these factors in Western and Asian countries. Japanese subjects consisted of 38 patients with anorexia nervosa restricting type (AN-R), 46 patients with anorexia nervosa binge eating/purging type (AN-BP), 76 patients with bulimia nervosa purging type (BN) and 99 controls. Subjects from the USA consisted of 29 AN-R, 34 AN-BP and 16 BN. The Physical and Sexual Abuse Questionnaire was administered to all subjects. Minor sexual abuse such as confronting exhibitionism or being fondled by a stranger tended to be more prevalent among Japanese subjects, while victimization by rape or incest was more prevalent among USA subjects. Conversely, physical abuse history was similarly distributed across each diagnostic subgroup in both countries. Events related to physical abuse, such as an abusive family background, may contribute whether eating disorder patients are restricting or bulimic and regardless of culture.     

A taxometric investigation of the latent structure of eating disorders

The present study examined the latent structure of eating disorder symptoms in a large sample of patients with a diagnosis of anorexia nervosa restricting type, anorexia nervosa binge eating/purging type, and bulimia nervosa (n=3747). Three taxometric procedures (MAXimum EIGenvalue (MAXEIG), Mean Above Minus Below A (MAMBAC), and Latent-Mode Factor Analysis (L-Mode)) were applied to self-reported symptoms of bulimia, drive for thinness, body dissatisfaction, as well as body mass index. Taxometric analysis among patients with the restricting and binge eating/purging subtype of anorexia and those with bulimia nervosa supported a dimensional latent structure of eating disorder symptoms. Taxometric analysis also revealed a dimensional latent structure of eating disorder symptoms among patients with the restricting and binge eating/purging subtype of anorexia suggesting that the two anorexia subtypes may not represent discrete categories. These findings suggest that the diagnosis and assessment of eating disorder symptoms should be conceptualized from a dimensional framework.     

Psychopharmacotherapy of anorexia nervosa, bulimia nervosa and binge-eating disorder

Pharmacotherapy for anorexia nervosa is considered to be of limited efficacy. However, many studies suffer methodological limitations, and the utility of newer drugs in the treatment of anorexia has not been examined yet. Although there have been more fruitful investigations on the efficacy of medication in the management of bulimia nervosa, there are still many unresolved issues regarding the optimal management of partial remission during the acute treatment phase and the intensity and duration of pharmacotherapy to achieve optimal prophylaxis. Selective serotonin reuptake inhibitors (SSRIs) control the binge urges in binge-eating disorder, but more trials are required to investigate the utility of SSRIs and other agents in maintenance treatment. We review the current status of psychopharmacotherapy for anorexia nervosa, bulimia nervosa and binge-eating disorder and evaluate the merits of newer agents in the treatment of these disorders.     

Cognitive-behavioral therapy for subthreshold bulimia nervosa: A case series

The extent to which cognitive-behavioral therapy (CBT) is helpful in treating individuals with bulimic symptoms who do not meet full criteria for bulimia nervosa is unclear. The purpose of this investigation was to examine the potential efficacy of CBT for eating disorder individuals with bulimic symptoms who do not meet full criteria for bulimia nervosa. Twelve participants with subthreshold bulimia nervosa were treated in a case series with 20 sessions of CBT. Ten of the 12 participants (83.3%) completed treatment. Intent-to-treat abstinent percentages were 75.0% for objectively large episodes of binge eating (OBEs), 33.3% for subjectively large episodes of binge eating (SBEs), and 50% for purging at end of treatment. At one year follow-up, 66.7% were abstinent for OBEs, 41.7% for SBEs, and 50.0% for purging. The majority also reported improvements in associated symptoms. This case series provides support for the use of CBT with individuals with subthreshold bulimia nervosa.     

The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication.

BACKGROUND: Little population-based data exist on the prevalence or correlates of eating disorders. METHODS: Prevalence and correlates of eating disorders from the National Comorbidity Replication, a nationally representative face-to-face household survey (n = 9282), conducted in 2001-2003, were assessed using the WHO Composite International Diagnostic Interview. RESULTS: Lifetime prevalence estimates of DSM-IV anorexia nervosa, bulimia nervosa, and binge eating disorder are .9%, 1.5%, and 3.5% among women, and .3% .5%, and 2.0% among men. Survival analysis based on retrospective age-of-onset reports suggests that risk of bulimia nervosa and binge eating disorder increased with successive birth cohorts. All 3 disorders are significantly comorbid with many other DSM-IV disorders. Lifetime anorexia nervosa is significantly associated with low current weight (body-mass index <18.5), whereas lifetime binge eating disorder is associated with current severe obesity (body-mass index > or =40). Although most respondents with 12-month bulimia nervosa and binge eating disorder report some role impairment (data unavailable for anorexia nervosa since no respondents met criteria for 12-month prevalence), only a minority of cases ever sought treatment. CONCLUSIONS: Eating disorders, although relatively uncommon, represent a public health concern because they are frequently associated with other psychopathology and role impairment, and are frequently under-treated.     

Effectiveness of individualized,integrative outpatient treatment for females with anorexia nervosa and bulimia nervosa

ABSTRACT

The effectiveness of an individualized outpatient program was investigated in the treatment of bulimia nervosa (BN) and anorexia nervosa (AN). Participants included 151 females who received outpatient eating disorder treatment in the partial hospitalization program, the intensive outpatient program, or a combination of the two programs. Outcome measures included the Eating Disorder Inventory (EDI-2), Beck Depression Inventory (BDI-II), frequency of binge eating and purging, and mean body weight. Findings included significant increases in weight for the AN group, reductions in binge eating frequency for the BN group, and reductions in EDI-2 and BDI-II scores and purging frequency for both groups. This study provides preliminary support for the efficacy of a multimodal program for the treatment of both anorexia nervosa and bulimia nervosa.     

Predictive validity of bulimia nervosa as a diagnostic category

OBJECTIVE: The authors sought to investigate the predictive validity of bulimia nervosa as a diagnostic category. METHOD: More than 10 years after they appeared as patients with bulimia nervosa, 177 women (participation rate=79.7%) completed follow-up assessments. RESULTS: Among the women with a current eating pathology, most engaged in recurrent binge eating and purging. Anorexia nervosa and binge eating disorder were relatively uncommon. Eating disorder outcome was significantly related to the presence of mood, substance use, and impulse control disorders but not to the presence of anxiety disorders. CONCLUSIONS: These results support the validity of bulimia nervosa as a diagnostic category that is distinct from anorexia nervosa. Furthermore, these results suggest that bulimic symptoms are associated with disorders involving distress and disinhibition.     

Self-help for bulimia nervosa: a randomized controlled trial

OBJECTIVE: The authors examined the effectiveness of unguided self-help as a first step in the treatment of bulimia nervosa. METHOD: A total of 85 women with bulimia nervosa who were on a waiting list for treatment at a hospital-based clinic participated. The patients were randomly assigned to receive one of two self-help manuals or to a waiting list control condition for 8 weeks. One of the self-help manuals addressed the specific symptoms of bulimia nervosa (cognitive behavior self-help), while the other focused on self-assertion skills (nonspecific self-help). RESULTS: Twenty patients (23.5%) dropped out of the study. The data were analyzed with intention-to-treat analysis. Although the group-by-time interaction for binge eating and purging was not statistically significant, simple effects showed that there was a significant reduction in symptom frequency in both self-help conditions at posttreatment but not in the waiting list condition. There were no statistically significant changes in levels of dietary restraint, eating concerns, concerns about shape and weight, or general psychopathology. A greater proportion of patients in the cognitive behavior self-help (53.6%) and nonspecific self-help (50.0%) conditions reported at least a 50% reduction in binge eating or purging at posttreatment, compared with the waiting list condition (31.0%). A lower baseline knowledge about eating disorders, more problems with intimacy, and higher compulsivity scores predicted a better response. CONCLUSIONS: The findings suggest that a subgroup of patients with bulimia nervosa may benefit from unguided self-help as a first step in their treatment. Cognitive behavior self-help and nonspecific self-help had equivalent effects.     

Lifetime substance abuse, family history of alcohol abuse/dependence and novelty seeking in eating disorders: Comparison study of eating disorder subgroups

Aim:  To assess lifetime substance abuse, family history of alcohol abuse/dependence, and novelty seeking in three different eating disorder groups (anorexia nervosa–restrictive; anorexia nervosa–binge eating/purging; anorexia nervosa to bulimia nervosa).
Method:  A total sample of 371 eating disorder patients participated in the current study. Assessment measures included the prevalence of substance abuse and family history of alcohol abuse/dependence as well as the novelty-seeking subscale of the Temperament and Character Inventory–Revised.
Results:  Significant differences across groups were detected for lifetime substance abuse, with anorexia nervosa–restrictive individuals exhibiting a significant lower prevalence than the anorexia nervosa to bulimia nervosa and anorexia nervosa–binge eating/ purging patients ( P  < 0.01). For family history of alcohol abuse/dependence the same pattern was observed ( P  = 0.04). Novelty seeking was associated with substance abuse ( P  = 0.002), with the anorexia nervosa to bulimia nervosa group exhibiting significantly higher scores on the novelty-seeking scale than the other two groups ( P  < 0.001). But family history of alcohol abuse/dependence was not related to novelty seeking ( P  = 0.092).
Conclusion:  Lifetime substance abuse appears to be more prevalent in anorexia nervosa patients with bulimic features. Higher novelty-seeking scores may be associated with diagnosis cross-over.     

Milnacipran: a comparative analysis of human monoamine uptake and transporter binding affinity.

BACKGROUND: Though selective serotonin reuptake inhibitors have revolutionized the field of psychiatry with demonstrated efficacy in affective and anxiety disorders with minimal side effects, norepinephrine-serotonin reuptake inhibitors may provide efficacy similar to tricyclic antidepressants without the adverse side effects associated with tricyclic antidepressants. METHODS: The affinity and selectivity of milnacipran, duloxetine, venlafaxine, citalopram, amitriptyline, and nortriptyline were determined for the human serotonin, norepinephrine, and dopamine transporters. RESULTS: Both milnacipran and duloxetine were potent inhibitors of serotonin and norepinephrine uptake. Unlike duloxetine and venlafaxine, milnacipran appears serotonin transporter selective in binding (ratio = 2.61) and norepinephrine transporter selective in uptake (ratio =.45). CONCLUSIONS: Milnacipran's binding and uptake inhibition profile more closely resembles that of the tricyclic antidepressants than that of duloxetine. Whether these differences observed in vitro manifest themselves in vivo is not clear.     

Medication management of pediatric eating disorders

This article provides an overview of psychopharmacological treatments for pediatric eating disorders (EDs). Although EDs usually begin in adolescence, there are few pharmacological treatment trials specific to this age group and a paucity of controlled data. Empirical evidence suggests that psychological, behavioural and family interventions should be the primary modalities of treatment for these conditions. In severely underweight patients behavioural weight restoration should be attempted before pharmacological intervention, especially since starvation is known to aggravate obsessional and depressive symptomatology. Evidence from controlled trials supports the use of antidepressants for the treatment of bulimia nervosa (BN) in adults; however, similar studies have not yet been performed in youths. For anorexia nervosa (AN), there are no pharmacotherapies of proven efficacy in either adults or youths. Nonetheless, clinical experience and uncontrolled evidence suggests that some children and adolescents may benefit from thoughtful use of psychotropic medications on an individual basis in the context of a multimodal treatment plan. Regarding binge eating disorder (BED), adult literature shows positive short-term effects on binge eating for both pharmacological (especially selective serotonin reuptake inhibitors) and behavioural interventions, but unclear effects on weight. Clearly, psychopharmacological interventions for pediatric EDs would benefit from more research.     

Medication management of pediatric eating disorders

This article provides an overview of psychopharmacological treatments for pediatric eating disorders (EDs). Although EDs usually begin in adolescence, there are few pharmacological treatment trials specific to this age group and a paucity of controlled data. Empirical evidence suggests that psychological, behavioural and family interventions should be the primary modalities of treatment for these conditions. In severely underweight patients behavioural weight restoration should be attempted before pharmacological intervention, especially since starvation is known to aggravate obsessional and depressive symptomatology. Evidence from controlled trials supports the use of antidepressants for the treatment of bulimia nervosa (BN) in adults; however, similar studies have not yet been performed in youths. For anorexia nervosa (AN), there are no pharmacotherapies of proven efficacy in either adults or youths. Nonetheless, clinical experience and uncontrolled evidence suggests that some children and adolescents may benefit from thoughtful use of psychotropic medications on an individual basis in the context of a multimodal treatment plan. Regarding binge eating disorder (BED), adult literature shows positive short-term effects on binge eating for both pharmacological (especially selective serotonin reuptake inhibitors) and behavioural interventions, but unclear effects on weight. Clearly, psychopharmacological interventions for pediatric EDs would benefit from more research.     

Intensive psychiatric treatment system for bulimic patients by group therapy]

Concurrent bulimia nervosa/purging type and anorexia nervosa/binge-purging type including binge eating and purging behaviors are considered chronic types of eating disorders. The bulimic patients in this study had both these disorders. Psychiatric treatment for patients with eating disorders must focus on therapy of these bulimic patients, because bulimic patients are more prevalent in the psychiatric hospital and clinic, and they have more comorbid psychiatric disorders and more other addictive behaviors than other patients with eating disorders. We have devised an intensive psychiatric treatment system for bulimic patients by group therapy that consists of inpatient treatment, group therapy for parents and group rehabilitation. Inpatient treatment, called the Eating Disorders Education Program (EDEP), consists of group psychological education, group cognitive-behavioral therapy, group nutrition education, and group exercise. Group therapy for parents consists of psychological education and group meetings. Group rehabilitation consists of many group activities in a house named "Mimoza". Bulimic patients come to understand their own disorders and symptoms objectively and understand recovery from their disorders by the intensive treatment system. Bulimic patients generally recover very slowly from eating disorders, but our intensive psychiatric treatment system promotes rapid recovery.     

Relapse predictors of patients with bulimia nervosa who achieved abstinence through cognitive behavioral therapy

BACKGROUND: Little information exists on relapse in patients with bulimia nervosa who responded with complete abstinence from binge eating and purging to cognitive behavioral therapy. Identification of relapse predictors may be useful to design effective early intervention strategies for relapse of susceptible patients with bulimia nervosa. METHODS: This multisite study examined relapse in 48 patients with bulimia nervosa who had responded to cognitive behavioral therapy with complete abstinence from binge eating and purging. Structured interviews and questionnaires were used to assess patients before and after treatment and at 4 months after treatment. RESULTS: Four months after treatment, 44% of the patients had relapsed. Those who relapsed had a higher level of preoccupation and ritualization of eating and less motivation for change, and had maintained abstinence for a shorter time during the treatment period. CONCLUSIONS: The predictors of relapse found in this study can be readily determined by clinicians. The effectiveness of early additional treatment interventions needs to be determined with well-designed studies of large samples.     

Anorexia nervosa patients with a prior history of bulimia nervosa

OBJECTIVES: To investigate clinical and psychological features of patients with anorexia nervosa (AN) with a previous history of bulimia nervosa. METHOD: Three hundred thirty-three patients with a full diagnosis of AN were assessed by the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, the Eating Disorders Inventory, and the Hopkins Symptom Checklist. RESULTS: Twenty-four patients (7%) reported a previous diagnosis of bulimia nervosa and were compared with a control group of 48 patients without a history of bulimia, matched for diagnostic subtype. Among the patients with a history of bulimia nervosa, 11 were of the restricting type and 13 of the binge eating/purging type. Among restricting anorexic patients, those with a history of bulimia reported greater age of onset, more psychiatric symptoms, more family psychiatric morbidity, and a higher rate of sexual abuse. On the contrary, among patients with the AN bingeing-purging subtype, the presence of a previous bulimia nervosa was not associated with any of the investigated variables. CONCLUSIONS: Patients with restricting AN who report a history of previous bulimia nervosa are not frequent among those referring to an outpatient eating disorders unit. However, our findings in this small group of subjects confirm that a lifetime history of bingeing and purging in patients with eating disorder, irrespective of when it occurs, is always associated with more psychopathology compared with those restricting patients with AN who have never had a period of bingeing and purging.     

A placebo-controlled study of fluoxetine in continued treatment of bulimia nervosa after successful acute fluoxetine treatment.

OBJECTIVE: The efficacy of fluoxetine in the acute management of bulimia nervosa is well established; however, few controlled studies have examined whether continuation of pharmacotherapy provides protection from relapse. This study compared the efficacy and safety of treatment with fluoxetine versus placebo in preventing relapse of bulimia nervosa during a 52-week period after successful acute fluoxetine therapy. METHOD: Patients who met DSM-IV criteria for bulimia nervosa, purging type, were assigned to single-blind treatment with 60 mg/day of fluoxetine. After 8 weeks of treatment, patients were considered responders if they experienced a decrease > or =50% from baseline in the frequency of vomiting episodes during 1 of the 2 preceding weeks. Responders were randomly assigned to receive 60 mg/day of fluoxetine or placebo and were monitored for relapse for up to 52 weeks. Patients met relapse criteria if they experienced a return to the baseline vomiting frequency that persisted for 2 consecutive weeks. RESULTS: Of the 232 patients who entered the acute phase, 150 patients (65%) met response criteria and were randomly assigned to receive fluoxetine (N=76) or placebo (N=74). Fluoxetine-treated patients exhibited a longer time to relapse than placebo-treated patients. Quantitative analysis of other efficacy measures, including frequency of vomiting episodes, frequency of binge eating episodes, Clinical Global Impression severity and improvement scores, the patient's global impression score, and Yale-Brown-Cornell Eating Disorder Scale score, indicated that the efficacy of fluoxetine treatment was statistically superior, compared to placebo. There were no clinically relevant differences in safety between groups. Attrition in this study was high, especially in the first 3 months after random assignment to treatment groups. CONCLUSIONS: Continued treatment with fluoxetine in patients with bulimia nervosa who responded to acute treatment with fluoxetine improved outcome and decreased the likelihood of relapse.     

Family-based therapy for adolescents with bulimia nervosa

Bulimia nervosa is occurring with increasing frequency among adolescents. Yet, no studies have examined effective treatments for this patient population. Involving the family in the treatment of adolescents with anorexia nervosa has proven to be helpful. A small series of cases has demonstrated that family-based treatment might also be beneficial for adolescents with bulimia nervosa. Moreover, treatment studies for adolescents with anorexia nervosa have demonstrated that family-based treatment does benefit binge eating/purging anorexics. Therefore, preliminary evidence seems to support the use of family-based treatment for adolescent bulimia nervosa. In this article, we review our current knowledge of family-based treatment for adolescents with an eating disorder, and present a case that has completed treatment in order to demonstrate the outline and main interventions of this manualized treatment. While this case demonstrates the successful resolution of bulimia in an adolescent female, at least in the short term, the efficacy of family-based treatment for this patient population is yet to be determined, and is currently being examined in a randomized controlled study at The University of Chicago.     

Comorbidity of eating disorders with bipolar disorder and treatment implications

OBJECTIVES: To review the scientific evidence examining the comorbidity among eating disorders and bipolar disorder (BD). METHODS: We reviewed all published English-language studies addressing the comorbidity of anorexia nervosa, bulimia, bulimia nervosa, and binge eating disorder in patients with BD and studies of comorbidity of BD in patients with eating disorders. In addition, we discuss the pharmacologic treatment implications from reviewed studies of agents used in BD and eating disorders. RESULTS: Community and clinical population studies of the lifetime prevalence rates of eating disorders in patients with BD, and of BD in patients with eating disorders, particularly when subthreshold and spectrum manifestations of these disorders are included, indicate high rates of comorbidity among these illnesses. CONCLUSIONS: Pharmacologic treatment approaches to patients with BD and a co-occurring eating disorder require examination of the possible adverse effects of the treatment of each syndrome on the other and attempts to manage both syndromes with agents that might be beneficial to both.